Local Agency Certification Self-Review Tool

Staff Person/Title:______Date:______

Participant ID Number:______Category / Age: ______

Start Time:______End Time:______Reviewer: ______

Required certification information: Rate Counselor on whether task is completed appropriately

Y / N / N/A / Comments
Continuity of Care
Reviewed notes / alerts / goals from previous visit
Establishing Rapport
Staff Introduced self / clinic procedures explained
Displayed understanding for other culture
Focused on client when translator used
Ensured Privacy (low voice – close door at client request)
Offered help when needed (books, toys for child, room to BF etc)
Used appropriate non-verbal communication
Used respectful language
Pre-Cert / Family / Participant Information (spelling, information verified and documented)
Name, Phone number, Street/Mailing address, Birth date, Family size
Income verified – Foster Care status documented if applicable
Voter registration status, internet access status
Designee options explained / “Right to sign R&R” box “checked” if needed
Proof of Identity
Adjunct Eligibility
Race / Ethnic Background / Asked about participation in other assistance programs (was purpose of these questions explained)
Proof of Pregnancy if applicable
Mother’s ID documented on infant screen if BF / completed BF statistics
Cert Action / Rights and Responsibilities
Correct Category / Cert Reason / Cert Period assigned and explained
Information on WIC Folder reviewed (initial visit and as needed)
Immunization Screen updated – R&R signed at appropriate location
R&R explained / Client given an opportunity to read – ask questions
R&R signed correctly by certifier and participant
Complaint and Fair Hearing Processes reviewed
Food Prescription / Follow up Appointment / Check issuance
Appropriate schedule day / clinic confirmed
Authorized Food List explained / clarified
Food package assigned appropriate for category / preference – foods explained
Issue month correct – clients checks eligible to spend on date of appt.
Appropriate next appointment scheduled
For new applicants – rules for check use explained – video shown
Assessment / Nutrition Education
Height, weight, hemoglobin performed according to P&P
Infection control procedures followed
Lead Screening question asked – clarified response if needed
Appropriate risk factors assigned
High Risk Form / completed / procedure followed

Skills checklist – Rate Counselor on a scale of 1-3 on how well each skill is performed

Note: Staff is not expected to use every skill with every client – check only those that apply

1 = Needs practice 2 = Meets Objective 3 = Excellent Job / 1 / 2 / 3 / Comments
Assessment / Nutrition Education (continued)
Reviewed client’s medical screen and health history information – asked probing questions to clarify responses
Avoided spending extensive time on irrelevant information
Shared findings (Ht/Wt/Iron) in a non-judgmental manner
Asked open-ended questions to explore client’s concerns
Listened actively and allowed for silence
Asked about / validated clients concerns / met need
Maintained focus on desired health (ie healthy pregnancy, active family)
Used Nutrition Basics info / visual aides to start and guide conversation
Identified and acknowledged clients strengths (positive behaviors)
Attempted to foster discussion based on risk factors if nothing offered by client - Provided simple, accurate nutrition message if client receptive
Limited number of nutrition messages given to client per session
Tailored message based on client’s age, gender, culture and feedback
Provided handouts to reinforce nutrition message – topics of interest pointed out (don’t forget - iron, lead, breastfeeding, formula prep, tooth decay )
Referrals / Setting Goals / Closure
Referred clients to outside sources when needed (DSS, food banks, BF)
Worked with client to identify problem behaviors and ideas for change
Summarized conversation
Helped client set goal(s) that is specific & realistic for the family’s lifestyle
Documented goals / nutrition topics on the Nutrition Ed screen of WoW
Restated goal and checked for understanding
Expressed appreciation for clients time
Was enthusiastic about following up at next visit
Documented notes / alerts appropriately
Follow up with staff member
Parent’s / Caregiver’s Primary Concern: / Assigned Risk Factors:
Nutrition Topics discussed:
Suggestions / Feedback / Discussion
Sample questions…”Tell me about your rational for the Nutrition Education topics you discussed”
“Tell me how you assessed the clients readiness for change”

Developed by WashingtonCounty WIC Program